Post a copy in a prominent location in facility, near telephone.
Licensee is responsible for updating information as required.
Return a copy to the licensing office.
NAME OF FACILITY ADMINISTRATOR OF FACILITY
FACILITY ADDRESS (NUMBER, STREET, CITY, STATE, ZIP CODE) TELEPHONE NUMBER
( )
I. ASSIGNMENTS DURING AN EMERGENCY (USE REVERSE SIDE IF ADDITIONAL SPACE IS REQUIRED)
NAME(S) OF STAFF
TITLE ASSIGNMENT
1. DIRECT EVACUATION AND PERSON COUNT
2. HANDLE FIRST AID
3. TELEPHONE EMERGENCY NUMBERS
4. TRANSPORTATION
5. OTHER (DESCRIBE)
6.
II. EMERGENCY NAMES AND TELEPHONE NUMBERS
(IN ADDITION TO 9-1-1)
POLICE OR SHERIFF OFFICE OF EMERGENCY SERVICES
RED CROSS POISON CONTROL
HOSPITAL(S) OTHER AGENCY/PERSON
CHILD PROTECTIVE SERVICES
III. FACILITY EXIT LOCATIONS
(USING A COPY OF THE FACILITY SKETCH [LIC 999] INDICATE EXITS BY NUMBER)
1. 2.
3. 4.
IV. TEMPORARY RELOCATION SITE(S)
(IF AVAILABLE, SUBMIT LETTER OF PERMISSION FROM RENTER/LEASSOR/MANAGER/PROPERTY OWNER)
NAME ADDRESS
NAME ADDRESS
V. UTILITY SHUT—OFF LOCATIONS
(INDICATE LOCATION(S) ON THE FACILITY SKETCH [LIC 999])
TELEPHONE NUMBER
( )
TELEPHONE NUMBER
( )
ELECTRICITY
WATER
GAS
VI. FIRST AID KIT (LOCATION)
VII. EQUIPMENT
SMOKE DETECTOR LOCATION (IF REQUIRED)
FIRE EXTINGUISHER LOCATION (IF REQUIRED)
TYPE OF FIRE ALARM SOUNDING DEVICE (IF REQUIRED)
LOCATION OF DEVICE
VIII. AFFIRMATION STATEMENT
AS ADMINISTRATOR OF THIS FACILITY, I ASSUME RESPONSIBILITY FOR THIS PLAN FOR PROVIDING EMERGENCY SERVICES AS
INDICATED BELOW. I SHALL INSTR
UCT ALL CLIENTS/RESIDENTS, AGE AND ABILITIES PERMITTING, ANY STAFF AND/OR
HOUSEHOLD MEMBERS AS NEEDED IN THEIR DUTIES AND RESPONSIBILITIES UNDER THIS PLAN.
SIGNATURE DATE
LIC 610 (10/03) (PUBLIC)
